INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on Deceber 4-5, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Psychiatric Institute was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of twelve client records, the facility failed to obtain a completed informed and voluntary consent which includes specific information disclosed in five out of twelve client records.
Client #2 was admitted on July 27, 2023 and was still active at the time of the inspection. A release of information for the funding source was signed on July 27, 2023 that failed to included the specific information to be disclosed.
Client #3 was admitted on August 15, 2023 and was still active at the time of the inspection. A release of information for the funding source was signed on August 22, 2023 that failed to include the specific information to be disclosed.
Client #5 was admitted on November 10, 2022 and was still active at the time of the inspection. A release of information for the funding source was signed on November 24, 2023 that failed to include the specific information to be disclosed.
Client #8 was admitted on August 4, 2023 and was still active at the time of the inspection. A release of information for the funding source was signed on August 4, 2023 that failed to include the specific information to be disclosed.
Client #9 was admitted on October 15, 2019 and discharged on October 27, 2023. A release of information for the funding source was signed and dated September 16, 2023 that failed to include the specific information to be disclosed.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
1. Re-training for all staff on how to complete consents to be done, and hand-outs for future reference to be provided. Re-training of all staff to be completed by 1/12/24.
2. Monitoring of compliance with consent completion to be done with monthly chart audits by Office Coordinator and Clinical Manager.
3. Client #2, consent to be resolved on 1/3/24 (next scheduled attendance date).
4. Client #3, unable to resolve due to being currently incarcerated and guest dosing elsewhere.
5. Client #5, consent to be resolved on 1/5/24 (next scheduled attendance date).
6. Client #8, unable to resolve due to discharge on 9/18/23.
7. Client #9, unable to resolve due to discharge on 10/27/23.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed written consent prior to administering an agent in one of twelve applicable records.
Patient #2 was admitted on July 27, 2023 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Re-training for all staff on necessity of patient signatures on all intake consents, and how to complete them. Re-training of all staff to be completed by 1/12/24.
2. Monitoring of compliance with consent completion to be done with monthly chart audits by Office Coordinator and Clinical Manager.
3. Client #2, consent to be resolved on 1/3/24 (next scheduled attendance date).
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in five of seven applicable records reviewed.
Patient #1 was admitted on May 9, 2023 and was still active at the time of the inspection. In October 2023 that patient had documentation of 2 individual hours and in November 2023 that patient had documentation of 1.5 individual hours.
Patient #2 was admitted on July 27, 2023 and was still active at the time of the inspection. In October 2023 that patient only had documentation of 1.45 individual hours.
Patient #3 was admitted on August 15, 2023 and was still active at the time of the inspection. In September 2023, that patient had no documentation of psychotherapy hours. October 2023, that patient had documentation of 2 individual hours and November 2023 had documentation of 1 individual hour.
Patient #4 was admitted on February 13, 2023 and was still active at the time of the inspection. In September 2023, the patient had documentation of 1 hour of individual hours, in October 2023, that patient had documentation of 1 individual hour and no documented hours in November 2023.
Patient #7 was admitted on February 21, 2018 and discharged on November 16, 2023. In October 2023, the patient only had documentation of 1 hour of psychotherapy.
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This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Re-training for all counseling staff to be completed by 1/5/24, regarding counseling hour requirements and documentation practices.
2. Documentation of all attended appointments, cancellations/ rescheduled, no-shows will be documented in patient chart.
3. Documentation of all outreaches to engage patients to schedule appointments will be documented in patient chart.
4. Counseling staff will utilize various engagement tools; stop dose holds, treatment agreements, warning letters, etc. to re-engage patients that have not been attending clinic or scheduled appointments. Such engagement tools will be documented in patient chart.
5. Monitoring of compliance with caseload counseling hour completion and documentation to be done with Monthly Chart review by Clinical Manager and Lead Counselor/ Clinical Supervisor.
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